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CLINICAL AND EPIDEMIOLOGIC RESEARCH

Neuropsychological Assessment of 412 HIV-Infected

Individuals in Sa

˜o Paulo, Brazil

Maria Rita Polo Gasco´n, PhD,

1

Jose´ Ernesto Vidal, PhD,

2

Yolanda Marques Mazzaro,

1

Jerusa Smid, PhD,

2

Rosa Maria Nascimento Marcusso,

2

Claudio Garcia Capita˜o, PhD,

2

Elizeu Macedo Coutinho, PhD,

3

Glaucia Rosana Guerra Benute, PhD,

1

Mara Cristina Souza De Lucia, PhD,

1 and Augusto Ce´sar Penalva de Oliveira, PhD 4

Abstract

HIV-associated neurocognitive disorders (HAND) remain frequent even among individuals receiving combined

antiretroviral therapy (cART). In addition, HAND may adversely affect the quality of life and adherence to cART.

There is scarce epidemiological information about HAND in Latin America. This cross-sectional study recruited

HIV-infected patients from a tertiary teaching institution in Sa o Paulo, Brazil, between May 2013 and February

2015. The patients were adults with at least 4 years of education and patients with current neurological or

psychiatric diseases were excluded. HAND remain frequent even among individuals receiving cART, use of

psychoactive substance, or inability to understand the content for neuropsychological evaluation. We used

standardized tools to evaluate depression, use of psychoactive substances, and daily life activities, and we

performed a comprehensive neuropsychological examination. HAND was classified using the Frascati criteria.

Prevalence of HAND was estimated, and an associated variable of symptomatic HAND was identified by logistic

regression. Four-hundred twelve HIV-infected patients were included [male: 281 (68%), mean age of 45.3 years].

Most of them [n=340 (83.7%)] had an undetectable viral load. The prevalence of HAND was 73.6% (n=303):

210 (50.9%) had asymptomatic neurocognitive involvement (ANI), 67 (16.2%) had mild neurocognitive disorder

(MND), and 26 (6.3%) had HIV-associated dementia (HAD). The univariate logistic regression analysis showed

that female gender, age older than 50 years,<11 years of schooling, CD4 count below 200 cells/mm3 , presence of

previous illnesses (e.g., diabetes, hypertension), opportunistic disease history, and a Beck Depression Inventory

(BDI) score between 13 and 19 points were factors associated with symptomatic HAND (MND and HAD).

However, a BDI score between 13 and 19 points was the single independent variable associated with symptomatic

HAND. HAND was highly prevalent in Sa

o Paulo, Brazil, and ANI was the more frequent category of HAND.

However, 22.5% of participants had symptomatic HAND. This finding constitutes a challenge in clinical practice.

A BDI score between 13 and 19 points was the single independent variable associated with symptomatic HAND.

Keywords:AIDS dementia complex, neurocognitive disorders, central nervous system, HIV, acquired im- munodeficiency syndromeIntroduction T he introduction ofcombined antiretroviral therapy (cART) has changed the natural history of HIV-associated neurocognitive disorders (HAND), stabilizing or improving symptoms in most of the severe cases. 1-3 Despite theseadvances, HAND continues to cause significant morbidity. However, there has been a decrease in the most severe form [HIV-associated dementia (HAD)] and an increase in the other categories [mild neurocognitive disorder (MND) and asymptomatic neurocognitive impairment (ANI)].4-8 Cur- rently, prevalence is estimated at 33% for ANI, 12% for 1 Division of Psychology, Central Institute of Hospital das Clinicas, Faculdade de Medicina de Sa˜ o Paulo, Sa˜ o Paulo, Brazil. 2 Department of Neurology, Institute of Infectology Emilio Ribas, Sa˜ o Paulo, Brazil. 3 Department of Psychology, Universidade Presbiteriana Mackenzie, Sa˜ o Paulo, Brazil. 4 Department of Neurology, Institute of Infectology Emilio Ribas, Sa˜ o Paulo, Brazil.AIDS PATIENT CARE and STDs

Volume 32, Number 1, 2018

ªMary Ann Liebert, Inc.

DOI: 10.1089/apc.2017.0202

1Downloaded by UCL /SWETS/28908077 from online.liebertpub.com at 01/12/18. For personal use only.

MND, and only 2% for HAD.

9

In addition, all HAND ca-

tegories can be observed in moderate or even discrete im- munosuppression levels 9-12 HAND categories can be dynamic and bidirectional, and several patterns can now be identified 1,4-8 making the im- mune scenario more complex because all HAND categories can be observed in moderate or even discrete immunosup- pression levels.

4,9,10

Interestingly, cohort studies of HAND

demonstrated the influence of low nadir CD4 counts, but not current CD4 counts or cART duration. 13

HAND may adversely affect the quality of life,

13 outpatient follow-up maintenance, and adherence to cART. 14

Therefore,

and the lack of epidemiological information on these com- plications in Latin America, the purpose of this study is to estimate the prevalence of HAND in Sa

˜o Paulo, Brazil.

Patients and Methods

A cross-sectional study was conducted with outpatients who received follow-up at the Institute of Infectious Diseases

EmilioRibas(IIER),Sa

˜oPaulo,Brazil,betweenMayof2013

and February of 2015. The IIER is a tertiary teaching insti- tution and referral center for patients with infectious diseases in Brazil. diagnosis of HIV infection, a minimum of 18 years of age, at least 4 years of education—to avoid an important con- foundingcondition duetolackofschooling—, andtheability to understand and sign the informed consent form to partic- ipate in the study. The exclusion criteria were as follows: diagnosis of op- portunistic neurological diseases in activity (e.g., cerebral toxoplasmosis, tuberculous meningitis, cryptococcal menin- gitis, progressive multifocal leukoencephalopathy), diagno- sis of previous cognitive decline due to other types of dementia (e.g., Alzheimer"s disease, vascular dementia), current useofpsychoactive substance, inabilitytounderstand the necessary content for neuropsychological evaluation, coinfections (e.g., hepatitis C, hepatitis B, syphilis), psychi- atric disorders (e.g., schizophrenia), and patients who scored higher than 19 (moderate and severe depression degrees) on the Beck Depression Inventory (BDI), because the high in- cidence of psychologic symptoms among HIV-infected in- dividuals could be confounding the diagnosis of HAND. 15,16 Patients were approached at the IIER outpatient center, where they were invited to participate in the study. Then, the questionnaire to identify the inclusion and exclusion criteria was applied, and afterward, another date was scheduled for neuropsychological assessment and application of the stan- dardized tools. The clinical, demographic, and laboratory histories were evaluated, an interview was conducted through a structured questionnaire, and medical records as well as laboratory da- tabases were reviewed. The data collected included age, sex, date of HIV infection diagnosis, and transmission mecha- nism; clinical information on opportunistic and metabolic diseases; antiretroviral drugs history; and laboratory infor- mation on CD4 count, viral load quantification for HIV-1, hemoglobin, hematocrit, urea,creatinine, sodium, potassium, transaminase, lipid profile, and coinfection with hepatitis B or C and syphilis.HAND diagnosis was established according to the Frascati criteria (ANI, MND, and HAD), 7 and a Z score was also calculated.

The Alcohol, Smoking, and Substance Involvement

Screening Test (ASSIST questionnaire) was used to evaluate the use of psychoactive substances. 17

The Lawton question-

naire was used to evaluate daily life activities, 18 and the Beck Depression Inventory (BDI-II) was used to evaluate symp- toms of depression. 19 The neuropsychological profile of the patients was deter- mined by formal neuropsychological assessment consisting of the following instruments: (1) Intellectual Functions; subtest Vocabulary and Matrix Reasoning using WAIS-III scale, 20 (2) Attention/Information Processing speed; Trail

Making Test A and B

22
and WAIS-III Coding subtest; 20 (3) Memory: Short-term or Operational: Digit Span subtest in direct and indirect order using WAIS-III scale; 20

Immediate

and Delayed Hearing capacity: The Rey Auditory Verbal learning test; 21

Immediate and Delayed Visual capacity: Rey

Complex Figure Test;

22
(4) Executive functions: Trail

Making B;

23

Phonemic Verbal Fluency Test (FAS)

24
and

Categorical Verbal Fluency (Animal Naming);

25
(5) Vi- suospatial and visuoconstructive functions: Rey Complex

Figure Test;

22
(6) Motor skills: Grooved Pegboard 26
and

Finger Tapping Test.

27

The International HIV Dementia

Scale (IHDS) was used for cognitive screening.

28

The choice

of neuropsychological battery was made in accordance with the Frascati meeting recommendations. 7 A database was created with the collected data and pro- cessed by means of descriptive statistics, with percentage, median, and mean as well as standard deviation calculations. Prevalence of HAND and its categories were estimated. For the neuropsychological performance comparison among groups, variance analyses were performed for independent samples with 1 factor (one-way ANOVA) to identify poten- tial covariates associated with the participants" neu- ropsychological performance (gender, age, education, and depression). After the establishment of covariates, an anal- ysis of three groups was performed (ANCOVA) to eliminate the effect of these covariates, thereby reducing the variance error. The Bonferroni post hoc test was used to identify sta- tistical differences in pairs ofgroups. Toidentify specific risk factors of symptomatic HAND (HAD and MND) prevalence, the variables were dichotomized using thev 2 test, and p<0.02 was set as the significance level and evaluated through univariate regression. The evaluation of associated variables to symptomatic HAND was calculated by logistical regression. All quantitative analyses were performed using SPSS (21.0) andp<0.05 was set as significance level.

Results

In this study, 1331 HIV-infected persons were screened to participate. Of these, 919 were excluded (Fig. 1). Finally, 412 individuals were included. The sample con- sisted mostly of male participants 281 (68%), having a mean age of 45.30 years [standard deviation (SD)=10.70], pre- dominantly single 209 (51.7%) and a mean education of

12.07 (SD=3.59).

Using the HAND classification criteria, we found 109

2GASCO´N ET AL.Downloaded by UCL /SWETS/28908077 from online.liebertpub.com at 01/12/18. For personal use only.

participants (50.9%) with ANI, 67 participants (16.2%) with MND, and 26 participants (6.3%) with HAD. The associa- tions that presented statistical significance found in the as- sociation for HAND were as follows: female gender (p<0.01); years of education (p<0.01); prior opportunistic disease (p=0.04); and prior disease (p<0.01). Table 1 shows the demographic and clinical characteristics of the participants, depending on the HAND classification. Demographic data were evaluated, and their statistical association with forms of HAND classification was per- formed according to the impairment degree, that is, the analysis was performed with the classifications ‘‘without neurocognitive changes"" and ANI versus MND and HAD. Statistical significance was found between HAND classifi- cations and age (p=0.04); gender (p=0.01); years of edu- cation (p=0.04); prior opportunistic disease (p<0.01); and prior disease (p<0.01) (Table 2). Table 3 shows the laboratorial results, use of efavirenz and BDI score of the participants, depending on the HAND classification. Most patients included in this study showed immunological and virological control. The CD4 mean (SD) was 625.78 (291.09), and 340 (83.7%) of participant had not use efavirenz (62.1%), and there was no statistical asso- ciation between efavirenz use and symptomatic HAND. Table 4 shows similar variables than Table 3 in grouping the HAND categories (‘‘without neurocognitive changes"" and ANI versus MND and HAD). Only BDI score showed statistical difference (p<0.01). The univariate logistic regression analysis showed that female gender, age older than 50 years,<11 years of educa- tion, presence of prior diseases (e.g., diabetes, hypertension),

opportunistic disease history, and a BDI score between 13and 19 points were variables significantly associated with

symptomatic HAND (MND and HAD) (Table 5). However, multiple logistic regression analyses identified that the single variable that remained independently associated with the and 19 points (Table 6).

Discussion

In this study, a high prevalence of HAND was found (73.5%) among 412 outpatients at a referral center in Sa ˜o Paulo, most of them under immunological and virological control. The prevalent HAND categories were as follows: ANI: 50.9%; MND: 16.2%; and HAD: 6.3%. This result confirms that a significant number of patients continue to exhibit measurable cognitive dysfunction in the cART era, despite the fact that Brazil presents a well-structured HIV care program with universal and free access to cART. High HAND prevalence has also been described in some studies. 1,8

However, lower frequencies have usually been

described. A study conducted in the United States among

1555 HIV-infected individuals found a frequency of 47%.

7 Another study conducted in China among 134 HIV-infected patients found a HAND frequency of 37%. 29

In Brazil, the

observed frequency of HAND in two studies was around of 50%.
30,31
However, in one of these studies the target public was elderly with HIV, 30
while another study had the objec- tive of validating the IDHS questionnaire. 31
The high frequency of cognitive impairment identified in this study is justified, at least partially, by the neuropsycho- to detect cognitive changes. Several studies used IHDS and usually three or four neuropsychological instruments. 28-32
In

FIG. 1.Flowchart of screened, excluded, and included HIV-infected persons. OBS: completar ‘‘919 patients excluded,""

no lugar de apenas ‘‘919 excluded."" Na

˜o consigo acrescentar no requadro.

HIV NEUROCOGNITIVE DISORDERS IN SA˜O PAULO, BRAZIL 3Downloaded by UCL /SWETS/28908077 from online.liebertpub.com at 01/12/18. For personal use only.

this study, in addition to IHDS, we used 12 neuropsycholo- gical instruments, which could have increased the sensitivity of the assessment. In our study, there were a higher proportion of patients with ANI (50.9%). The clinical implications of this HAND cate-

gory are still controversial and are usually reserved for re-search. Nevertheless, longitudinal results of the CNS HIV

thatpatientswith ANI atbaselinewere from 2 to 6 times more likely to develop symptomatic HAND during varying time periods during the follow-up, when compared with those considered normal. 8 Table2.Demographic and Clinical Characteristics of412HIV-Infected

Persons with Neurocognitive Evaluation

Variable Category

Total (n=412)MND/HAD (n=93)ANI (n=210)Without HAND (n=109) Sign. Age (years)<=50 271 (65.8%) 53 (57%) 143 (68.1%) 75 (68.8%) >50 141 (34.2%) 40 (43%) 67 (31.9%) 34 (31.2%)p=0.12 Gender Male 281 (68.2%) 54 (58.1%) 150 (71.4%) 77 (70.6%) Female 131 (31.8%) 39 (41.9%) 60 (28.6%) 32 (29.4%)p=0.05 Education<=11 219 (53.2%) 61 (65.6%) 113 (53.8%) 45 (41.3%) (years)>11 193 (46.8%) 32 (34.4%) 97 (46.2%) 64 (58.7%)p=0.03 Prior opportunistic Occurrence 97 (23.5%) 29 (31.2%) 41 (19.5%) 27 (24.8%) Disease Absence 315 (76.5%) 64 (68.8%) 169 (80.5%) 82 (75.2%)p=0.08 Prior Occurrence 90 (21.8%) 33 (35.5%) 37 (17.6%) 20 (18.3%) Disease Absence 322 (78.2%) 60 (64.5%) 173 (82.4%) 89 (81.7%)p=0.01 Infection<14 165 (41.7%) 34 (38.2%) 89 (44.3%) 42 (39.6%) Time>=14 231 (58.3%) 55 (61.8%) 112 (55.7%) 64 (60.4%)p=0.55 Transmission Sexual 341 (82.8%) 75 (80.6%) 166 (79%) 100 (91.7%) Form Vertical 22 (5.3%) 7 (7.5%) 11 (5.2%) 4 (3.7%)quotesdbs_dbs26.pdfusesText_32

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